Luke O. Hansen, MD, MHS; Robert S. Young, MD, MS; Keiki Hinami, MD, MS; Alicia Leung, MD; Mark V. Williams, MD
Acknowledgment: The authors thank Linda O'Dwyer, MA, MSLIS, for assistance in the development of the initial database query for this review.
Grant Support: By the Northwestern University Feinberg School of Medicine (all authors). Drs. Williams and Hansen have received financial support from the John A. Hartford Foundation and the Society of Hospital Medicine for Project BOOST (Better Outcomes for Older Adults Through Safe Transitions). Dr. Young is supported by a National Research Service Award postdoctoral fellowship grant through the Institute for Healthcare Studies at Northwestern University under institutional awards from the Agency for Healthcare Research and Quality (T-32 HS 000078).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1422.
Requests for Single Reprints: Luke O. Hansen, MD, MHS, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 East Ontario Street, 07-733, Chicago, IL 60611; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Hansen: Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 East Ontario Street, 07-733, Chicago, IL 60611.
Dr. Young: Northwestern University Feinberg School of Medicine, 211 East Ontario Street, 7th Floor, Chicago, IL 60611.
Dr. Hinami: Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 East Ontario Street, 07-727, Chicago, IL 60611.
Dr. Leung: Northwestern University Feinberg School of Medicine, 251 East Huron Street, Feinberg 16-738, Chicago, IL 60610.
Dr. Williams: Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 East Ontario Street, 7th Floor, Chicago, IL 60611.
Author Contributions: Conception and design: L.O. Hansen, R.S. Young, M.V. Williams.
Analysis and interpretation of the data: L.O. Hansen, R.S. Young, K. Hinami, M.V. Williams.
Drafting of the article: L.O. Hansen, R.S. Young, K. Hinami, M.V. Williams.
Critical revision of the article for important intellectual content: L.O. Hansen, R.S. Young, K. Hinami, A. Leung, M.V. Williams.
Final approval of the article: L.O. Hansen, R.S. Young, K. Hinami, M.V. Williams.
Statistical expertise: L.O. Hansen, R.S. Young.
Administrative, technical, or logistic support: M.V. Williams.
Collection and assembly of data: L.O. Hansen, K. Hinami, A. Leung, M.V. Williams.
Hansen L., Young R., Hinami K., Leung A., Williams M.; Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Ann Intern Med. 2011;155:520-528. doi: 10.7326/0003-4819-155-8-201110180-00008
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Published: Ann Intern Med. 2011;155(8):520-528.
About 1 in 5 Medicare fee-for-service patients discharged from the hospital is rehospitalized within 30 days. Beginning in 2013, hospitals with high risk-standardized readmission rates will be subject to a Medicare reimbursement penalty.
To describe interventions evaluated in studies aimed at reducing rehospitalization within 30 days of discharge.
MEDLINE, EMBASE, Web of Science, and the Cochrane Library were searched for reports published between January 1975 and January 2011.
English-language randomized, controlled trials; cohort studies; or noncontrolled before–after studies of interventions to reduce rehospitalization that reported rehospitalization rates within 30 days.
2 reviewers independently identified candidate articles from the results of the initial search on the basis of title and abstract. Two 2-physician reviewer teams reviewed the full text of candidate articles to identify interventions and assess study quality.
43 articles were identified, and a taxonomy was developed to categorize interventions into 3 domains that encompassed 12 distinct activities. Predischarge interventions included patient education, medication reconciliation, discharge planning, and scheduling of a follow-up appointment before discharge. Postdischarge interventions included follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory providers, timely ambulatory provider follow-up, and postdischarge home visits. Bridging interventions included transition coaches, physician continuity across the inpatient and outpatient setting, and patient-centered discharge instruction.
Inadequate description of individual studies' interventions precluded meta-analysis of effects. Many studies identified in the review were single-institution assessments of quality improvement activities rather than those with experimental designs. Several common interventions have not been studied outside of multicomponent “discharge bundles.”
No single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalization.
AzeemMajeed, Professor of Primary Care
Imperial College London
October 22, 2011
Tackling rehospitalizations in England's National Health Service
As in the USA, rehospitalizations impose a significant strain on the health system in England. In the 2008-09 financial year, 508,000 patients aged 16 years and over were rehospitalized within 28 days of discharge from a National Health Service (NHS) hospital in England. Around 11.2% of hospital admissions in this age group result in a rehospitalization, with a wide variation between both primary care practices and primary care trusts (the organizations in England's NHS responsible for overseeing local health services).
Many of the interventions examined in the systematic review by Luke Hansen and colleagues have been tried - with generally a similar lack of success - in England's NHS. Because of the considerable burden imposed by rehospitalizations on both patients' health and on NHS finances, the NHS continues to look for ways to address this issue. Fines for NHS hospitals have been advocated as one solution and the impact this will have on rehospitalizations remains to be seen. The other significant step being taken to address rehospitalizations is to give primary care physicians responsibility for managing their local health budgets. This imposes a collective responsibility on physicians to examine rehospitalizations in their patients and address their root causes. In my own primary care trust, this has led to detailed statistics on admissions for unplanned care being made available on primary care practices; critical review of patients who have experienced rehospitalizations by panels of physicians to identify factors that could have prevented the event; and system wide changes to develop alternative care pathways for patients at risk of rehospitalization.
Giving primary care physicians collective responsibility for health service budgets in their locality in an attempt to improve the efficiency of a health system in areas such as rehospitalizations is a radical step and one that physicians in other health systems should observe closely to learn about both its benefits on the health of patients and on health care efficiency; and also to identify any unintended adverse consequences that may arise from the policy.
1. NHS Information Centre. Emergency readmissions to hospital within 28 days of discharge : indirectly standardised percent, 16+ years, annual trend. http://goo.gl/SgmzQ
2. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Ann Intern Med October 18, 2011 155:520-528;
3. Roberts R. Hospitals to face financial penalties for readmissions. BBC News Online. http://www.bbc.co.uk/news/10262344
4. O'Flynn N, Potter J. Commissioning Health Care in England: An Evolving Story. Ann Intern Med October 4, 2011 155:465-469.
5. NHS Institute for Innovation & Improvement. Reduce readmissions. http://goo.gl/U0YFH
I am a general practitioner in the primary care practice of Dr Curran in Clapham, London. The Department of Primary Care at Imperial College London has received funding from the NHS for research on rehospitalizations.
Lewis G.Sandy, SVP, Clinical Advancement
November 9, 2011
Reducing Hospital Admissions: A Bayesian Approach to the Published Literature
While the authors should be commended for compiling a well written, thorough and timely review article, the paper's final paragraph ( particularly the final sentence) made me wince, raising a larger point about the evidence base (and sources of evidence needed) for system improvement and policy.
In contrast to the published literature, my observation of hospitals and hospital systems that undertake work in this area is that they generally acheive improvement in readmission rates, especially if they focus on it, are supported in their improvement efforts, and are incentivized to do so; there are well-studied interventions as the paper outlines; the Society For Hospital Medicine (SHM), the Institute for Healthcare Improvement (IHI) and others have robust initiatives in this area; our benefits company (UnitedHealthcare) has been successful in reducing hospital readmissions through combined in-market and telephonic inpatient care advocacy/transition management and engaging with facilities, and high performing ambulatory care systems are quite adept at reducing readmissions, again if incented to do so. All told, hospitals that seek to improve in this area have many resources to draw upon for improvement.
Thus, given what I would call the "preponderance of the evidence" I would consider a Bayesian approach to inference/policy, thinking of the published literature as a "low sensitivity" diagnostic test, applied to a patient with a high prior probability of disease. Thus while I agree that more evidence to guide practice would certainly be useful, I do not agree that "the current evidence base may not be adequate to facilitate change... and reconsideration of planned penalties may be reasonable." This would be an incorrect inference from the literature to policy in my view (like a false negative diagnostic test), and would reduce action and momentum in this important area.
Employee, stock/stock options: UnitedHealth Group. Comments are personal opinions of the author, and not the opinions or position of UnitedHealth Group or affiliated companies.
Luke O.Hansen, Assistant Professor, Mark V. Williams, Professor
Division of Hospital Medicine, Northwestern University Feinberg School of Medicine
November 28, 2011
Authors' response to reader comments
We agree with Dr. Sandy that thoughtful attention to care transitions will often result in lower readmission rates, with process change supported by some of the interventions we reviewed as well as culture shift to more safety awareness at discharge. However, these improvements are unlikely to be experienced by all hospitals. The key question for performance-based reimbursement tied to the readmission outcome is whether hospitals that demonstrate themselves to be laggards fall short because of factors that are under their control or not.
Many of the reports of success are observational, and we lack a robust evidence-base of randomized controlled trials (RCTs). We believe the hospital discharge transition is an event for which appropriate RCTs could be conducted, but research funding has been lacking. Additionally, because peer-reviewed literature is predominantly focused on the academic healthcare environment, we cannot be confident that non-academic sites of care, where most U.S. healthcare is delivered, can expect similar benefits from interventions. The importance of organizational context to organizational change raises concerns that many hospitals will be frustrated if they seek improvement by replicating the processes we reviewed in our paper.
We are particularly concerned about hospitals that may be left behind (and penalized) as national readmission rates fall in response to hospital financial incentives. We worry that intractable local or individual social factors explain many rehospitalizations. We are unable to estimate the extent of this because available models of rehospitalization risk prediction are insufficient, but it is likely that regional and patient -level socioeconomic variation affects post-discharge health.
Hospitals with opportunity for improvement around medical determinants of rehospitalization will likely see the most gains, particularly since current models adjust away the adverse effect of medical co-morbidity leaving only the potential gain of improved medical care. However, other hospitals who serve communities which lack community- based health and social welfare services (elements not adjusted-for in current models) may find themselves hitting a ceiling for improvement that places them at risk for classification as underperformers. The Centers for Medicare and Medicaid Service's exemption of critical access hospitals is an acknowledgement of this to some degree. We fear many sites will suffer penalties and be frustrated by ineffective hospital-based efforts to change outcomes.
Financial risk shared between the inpatient and outpatient care settings, as described in Dr. Majeed's letter and supported by sections of the Affordable Care Act, may prove both more fair and more effective.
Luke O. Hansen, MD MHS FACP, Mark V. Williams, MD FACP
1. Kansagara, D., et al., Risk Prediction Models for Hospital Readmission. JAMA: The Journal of the American Medical Association, 2011. 306(15): p. 1688-1698.
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